1174. Intern Ng. Rare uterine serosal inclusion cysts in a pyometra Golden Retriever

The Golden Retriever had profuse dark brown vaginal discharge - open pyometra diagnosed by the other vet on 12.1.15. Heat was 1 month ago. Vulval discharge 34 days. Vomited once  days ago.

X-rays and blood tests done. Advised immediate surgery as antibiotics may stop the discharge but this infection will recur. Costs would be $3,000. No more vaginal discharge at consltation in Toa Payoh Vets on 14.1.15

"As the life span of a Golden Retriever is around 12 years and this dog is 13 years," I told Dr Daniel who was discussing about alternative medical treatment to surgery. "The owner was thinking of euthanasia rather than take the anaesthetic risk of surgery. The fees still have to be paid if the dog dies on the op table!"

Spaying the dog young would have prevented such anaesthetic worries and financial costs. The dog was given IV drips with amino acids and antibiotics overnight.  More dirty vaginal discharge passed overnight. Operated by Dr Daniel in the afternoon and went home in the evening. Low dosage of Domitor and Ketamine at 0.1 ml + 0.1 ml IV plus isoflurane gas.

"Only after 7 days do we know whether your dog is back to normal," I advised the couple. Surrpising, this case had a large number of uterine cysts, so rare that I had not seen in over 100 pyometra cases done over the last 30 years. This is the first case of uterine cysts seen by me. I don't know whether other vets have had seen such occurrences. Cystic endometrial hyperplasia is part of the pyometra disease but such cysts are usually inside the uterus.


CHANCES OF SURVIVAL FROM ANAESTHESIA AND SURGERY
1. Age. 13 years old - very old for a Golden Retriever.
2. Kidney impairment. Vomited once only.
3. Duration of illness. Vaginal discharge said to be for 3 days.
4. Health is poor - Lethargic. Not standing or eating.
Blood test showed bacterial infection and blood loss. No kidney impairment. Abnormal values are:

  RBC 5.1   (5.5-8.5).
  Hb    14.3 (12-18)
  PLT   556 (175-500)

WBC  22.8  (5.5-17)|
NEU  14.8  (2-12)
MONO  3.8 (0.3-2)
EOS  2.2  (0.1 - 1.5)

Peripheral blood smear - normocytic normochromic erythrocytes. Adequate platelets.
Leucocytosis with neutrophila. Babesia negative

3. Anaesthesia. Isoflurane gas is best.  In this case, very low dose of Domitor 0.1 ml + Ketamine 0.1 ml IV was given before maintenance with gas. I noted that the dog was still drowsy post op. For old dogs, it is best not to wait for her to recover. Antisedan 0.1 ml reversed the domitor sedation and the dog was alert after 15 minutes. Went home in the evening.

4. Follow up 16.1.14  10.15 am, 19 hours post-operation.  Owner said the dog was very weak and would not go to the bathroom by herself. She ate a bit and he had to syringe feed her. I advised feeding 6 X/day. 

5. The first vet had prescribed Clavet 500 mg 1 tab bid and Tramadol 50 mg 1.5 tablets bid

VIDEO

FOLLOW UP ON DAY 7 AFTER SURGERY.   Jan 20, 2015 5 pm. Managed to reach the husband by phone. I was expecting the worst as the dog was so thin and was unable to stand up and ate less on Day 2. Day 1 is surgery day on Jan 13, 2015.
"The dog does not need to be lifted up since yesterday," the husband had also said that the dog had passed bloody discharge after the pyometra surgery. "For the past 6 days, she could not stand up."

I was glad to know that the dog had recuperated well. She ate more and drank normal amounts. Her stools and urine were normal.

"She is so thin that I was worried that she would pass away," I told Intern Ng. "Since she can survive 7 days and is walking by herself, she will likely live."

The first 7 days are critical. I had phoned the owner to tell him that the dog must be fed 3 times a day, instead of once. She has poor appetite and so should be fed more times.  I also gave the owner a high energy vitamin supplement to be given a tablespoon a day and he had asked to buy another tube.

MAKING A VIDEO. These are the pointers I gave to Intern Ng. Whether she can create a good movie of this ordinary pyometra case, depends on her ability. There are at least 5 conflicts.

1. Old dog likely to die under anaesthesia.
2. Thin old dogs have higher risks. They may die after surgery within the first 7 days.
3. Medical and surgical costs over $3000 as quoted by the first vet. So, is it more pragmatic to euthanase the dog since the money spent still has to be paid even if she dies on the op table? This was considered.
4. Reputational risk of the vet. Why operate high risk dogs and risk ruining his reputation?
5. Experience of vet. Immediate surgery advised by first vet. I would not advise it. Stabilise the dog first. The dog had 2 days of antibiotics and this eliminated the bacteria and enhance her chances of survival. 3 bottles of drip. 2 before and 1 after surgery.